Biopsychosocial History Form

1 Name _____ Patient ID _____ Patient SSN _____ Date _____ Date of Birth _____ Page 1. Biopsychosocial History Presenting Problems Primary _____. Secondary _____. _____. Current Symptom Checklist (Rate intensity of symptoms currently present). Mild = Impacts quality of life, but no significant impairment of day-to-day functioning Moderate = Significant impact on quality of life and/or day-to-day functioning Severe = Profound impact on quality of life and/or day-to-day functioning Symptom Impact Symptom Impact None Mild Moderate Severe None Mild Moderate Severe Aggressive Behaviors Laxative/Diuretic Abuse.

2 Agitation Loose Associations . Anorexia Mood Swings . Appetite Disturbance Obsessions/Compulsions . Bingeing/Purging Oppositional Behavior . Circumstantial Symptoms Panic Attacks . Concomitant Medical Condition Paranoid Ideation . Conduct Problems Phobias . Delusions Physical Trauma Perpetrator . Depressed Mood Physical Trauma Victim . Dissociative States Poor Concentration . Elevated Mood Poor Grooming . Elimination Disturbance Psychomotor Retardation . Emotional Trauma Perpetrator Self-Mutilation . Emotional Trauma Victim Sexual Dysfunction . Emotionality Sexual Trauma Perpetrator.

3 Fatigue/Low Energy Sexual Trauma Victim . Generalized Anxiety Significant Weight Gain/Loss . Grief Sleep Disturbance . Guilt Social Isolation . Hallucinations Somatic Complaints . Hopelessness Substance Abuse . Hyperactivity Worthlessness . Irritability Other . Name _____ Patient ID _____ Patient SSN _____ Date _____ Date of Birth _____ Page 2. Emotional/Psychiatric History Prior outpatient psychotherapy? No Yes If yes, on occasions. Longest treatment by for sessions from / to /. Provider Name Month/Year Month/Year Prior provider name City State Diagnosis Intervention/Modality Beneficial?

4 _____ _____ ____ _____ _____ _____. _____ _____ ____ _____ _____ _____. Has any family member had outpatient psychotherapy? No Yes If yes, who/why (list all): _____. _____. Prior inpatient treatment for a psychiatric, emotional, or substance use disorder? No Yes If yes, on occasions. Longest treatment at _____from / to /. Name of facility Month/Year Month/Year Inpatient facility name City State Diagnosis Intervention/Modality Beneficial? _____ _____ ____ _____ _____ _____. _____ _____ ____ _____ _____ _____. Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder?

5 No Yes If yes, who/why (list all): _____. _____. Prior or current psychotropic medication usage? If yes: No Yes Medication Dosage Frequency Start Date End Date Physician _____ _____ _____ _____ _____ _____. _____ _____ _____ _____ _____ _____. Has any family member used psychotropic medications? If yes, who/what/why (list all): No Yes _____. _____. Name _____ Patient ID _____ Patient SSN _____ Date _____ Date of Birth _____ Page 3. Family History Family of Origin Present during childhood Describe parents Present Present entire part of Not Present childhood childhood at all mother Father Mother full name _____ _____.

6 Father . occupation _____ _____. stepmother . education _____ _____. stepfather . general health _____ _____. brother(s) . sister(s) . other . Parents' current marital status Describe childhood family experience married to each other outstanding home environment separated for ____ years normal home environment divorced for ____ years chaotic home environment mother remarried ____ times witnessed physical/verbal/sexual abuse toward others father remarried ____ times experienced physical/verbal/sexual abuse from others mother involved with someone father involved with someone mother deceased for____ years age of patient at mother's death ____.

7 Father deceased for ____ years age of patient at father's death ____. Age of emancipation from home: _____. Circumstances that contribute to emancipation Special circumstances in childhood _____ _____. _____ _____. _____ _____. Immediate Family Marital status Intimate relationship Relationship satisfaction single, never married never been in a serious relationship very satisfied with relationship engaged months not currently in relationship satisfied with relationship married for years currently in a serious relationship somewhat satisfied with relationship divorced for years dissatisfied with relationship separated for years very dissatisfied with relationship divorce in process months live-in for years _____ prior marriages (self).

8 _____ prior marriages (partner). Name _____ Patient ID _____ Patient SSN _____ Date _____ Date of Birth _____ Page 4. List all persons currently living in patient's household Name Age Sex Relationship to Patient _____ _____ _____ _____. _____ _____ _____ _____. _____ _____ _____ _____. List biological / adopted children not living in same household as patient Name Age Sex Relationship to Patient _____ _____ _____ _____. _____ _____ _____ _____. _____ _____ _____ _____. Frequency of visitation of above: _____. Describe any past or current significant issues in intimate relationships _____.

9 _____. _____. Describe any past or current significant issues in other immediate family relationships _____. _____. _____. Medical History (check all that apply for patient). Describe current physical health Good Fair Poor _____. _____. List name of primary care physician Name _____ Phone _____. List name of psychiatrist (if any): Name _____ Phone _____. List any non-psychiatric medications currently being taken (give dosage and reason). _____. _____. List any known allergies _____. _____. Name _____ Patient ID _____ Patient SSN _____ Date _____ Date of Birth _____ Page 5. Is there a History of any of the following in the family tuberculosis heart disease birth defects high blood pressure emotional problems alcoholism behavior problems drug abuse thyroid problems diabetes cancer Alzheimer's disease/dementia mental retardation stroke other chronic or serious health problems _____.

10 Describe any serious hospitalization or accidents List any abnormal lab test results Year Age Reason Year Result _____ _____ _____ _____ _____. _____ _____ _____ _____ _____. _____ _____ _____ _____ _____. Substance Use History (check all that apply for patient). Family alcohol/drug abuse History father stepparent/live-in mother uncle(s)/aunt(s). grandparent(s) spouse/significant other sibling(s) children other _____. Substance use status Patient Treatment History no History of abuse outpatient (age[s]) _____. active abuse Inpatient (age[s]) _____. early full remission 12-step program (age[s]) _____.